**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, clinical record review, and document review, the facility failed to 1) ensure that 1 of 4 residents (Resident #97) investigated for abuse and/or neglect received the necessary care and services to prevent a wound from deteriorating and becoming infected, resulting in the resident requiring emergent care for sepsis at an acute care hospital, where the resident subsequently expired due to sepsis and 2) protect residents' right to be free from neglect when signs and symptoms of infection and a change in skin condition in 1 of 18 sampled residents (Resident #24) were not reported timely to the physician by a Licensed Practical Nurse (LPN), resulting in the resident experiencing testicular pain and swelling and developing an infection that required intravenous antibiotic treatment at an acute care hospital. This deficient practice resulted in harm to both residents, including one death and one hospitalization. Findings include: Resident #97 Resident #97 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including cellulitis, unspecified, idiopathic progressive neuropathy, localized edema, unspecified dementia, severe, with anxiety and paranoid schizophrenia. Resident #97's Order Summary Report documented the following orders: -Wound culture to left leg related to cellulitis, with an order date of [DATE]. There was not documented evidence of a culture being completed after this date. - A wound care order with a start date of [DATE], documented to cleanse and soak left dorsal foot venous statis ulcer with wound cleanser, dry, apply Medihoney, hydrofera blue (HFB), abdominal pad (ABD) wrap with Kerlix and Coban, every Wednesday, Friday, and Sunday (W/F/S) and as needed (PRN) soiling and dislodgement. Wound clinician to change on Wednesdays. -A wound care order with a start date of [DATE], documented to soak and cleanse the left lower extremity (LLE) with wound cleanser, pat dry, apply Medihoney to the affected areas of the lower extremity, cover with ABD pad, wrap with Kerlix, secure with Coban and tape on Wednesdays and Sundays and PRN soiling and/or dislodgement. Wound clinician to change on Wednesdays. The record did not specify lateral or posterior wounds and did not include a stop/end date for the order. -A wound care order dated [DATE], with a start date of [DATE], documented to cleanse the lateral LLE venous stasis ulcer with wound cleanser, apply HFB, cover with ABD pad, wrap with Kerlix every W/F/S and PRN soiling and/or dislodgement. Wound clinician to change on Wednesdays. -A wound care order dated [DATE], with a start date of [DATE], documented to cleanse the posterior LLE venous stasis ulcer with wound cleanser, apply HFB, cover with ABD pad, wrap with Kerlix and Coban every W/F/S and PRN soiling and/or dislodgement. -A wound care order dated [DATE], with a start date of [DATE], documented to cleanse and soak left dorsal foot venous statis ulcer with wound cleanser, dry, apply HFB, ABD pad wrap with Kerlix and Coban, every W/F/S, PRN soiling and/or dislodgement. Wound clinician to change on Wednesdays. Resident #97's Treatment Administration Record (TAR) for [DATE], documented wound care was not provided as ordered on [DATE], and [DATE] to the resident's left dorsal foot venous statis ulcer, lateral LLE wounds and posterior LLE wounds. A physician's order dated [DATE], documented to monitor the identified target behaviors related to antianxiety medication: 1) uncontrollable screaming/yelling out, 2) agitation, 3) other (document in a progress note), and 4) none noted, every shift for psychotropic symptom monitoring. Resident #97's TAR for [DATE], did not include evidence of monitoring for the resident's targeted behaviors related to antianxiety medications on 09/01, 09/03, 09/09, 09/10, 09/12, 09/13, 09/17, 09/18, 09/19, 09/20, 09/25, and [DATE] during day shift. A physician's order dated [DATE], documented an order for doxycycline hyclate oral tablet, 100 milligrams (mg), give one tablet by mouth two times per day for bacterial infection, for 10 days with a start date of [DATE], and a stop date of [DATE]. Resident #97's Medication Administration Record (MAR) documented doxycycline, and antibiotic medication, was not available at the facility on 09/14 and [DATE]. The first dose of the medication was administered on [DATE], and the last dose of the medication was administered on [DATE]. As a result, the resident received only eight days of the prescribed 10-day course. A nurse progress note dated [DATE], documented Resident #97 “uncontrollably” yelled in pain all day and nothing helped the resident's pain. Resident #97's left lower extremity (LLE) dressing was changed because the dressing was wet with a moderate amount of purulent drainage and a strong odor. Orders were obtained to send the resident to the emergency room for evaluation. A Nurse Progress note dated [DATE], related to antianxiety medication monitoring, documented Resident #97 continued to yell out and scream for help. The resident yelled uncontrollably, and the topics did not make sense. The resident appeared paranoid and complained of people trying to hurt the resident, being ignored, and the pain the resident was experiencing. A Nurse Progress note dated [DATE], documented Resident #97 shouted “can someone help me, can anyone help me, why won't nobody help me,” and “he is going to kill me, and you are going to kill me” for approximately two hours prior to falling asleep. The resident could not be redirected. A Behavior Note dated [DATE], written by the Assistant Director of Nursing (ADON) documented Resident #97 had yelled all day. The resident yelled “help me, why won't someone help me.” The resident verbalized the resident's legs “hurt so bad.” The wound dressing to Resident #97's right lower extremity (RLE) was soaked with purulent drainage. A Wound Note dated [DATE], documented a dressing change was completed for Resident #97's LLE lateral and posterior wounds, and the left dorsal foot. The resident was “noncompliant” and threatened, yelled, and screamed at staff. The resident flailed and kicked at staff prior to the completion of the wound care. The wound note did not document the characteristics of the wound including slough, drainage, odor, condition of the peri-wound, and/or size of the wound. A Nurse Note dated [DATE], documented Resident #97 “yelled and screamed” all night. The resident yelled “I need help, help me, I want you to be my friend, why are you mean to me, and my legs hurt.” Pain medication was given but did not appear to help. The resident could not be redirected. A Nurse Note dated [DATE], documented Resident #97 was taken to [NAME] City for an appointment and upon return transportation staff told the nurse Resident #97 had left a “puddle” of clear, no odorous drainage on the floor of the van. The drainage was from the resident's lower extremities and occurred during the few hours the resident was transported to [NAME] City and then back to the facility. A Wound Note dated [DATE], documented Resident #97's wound care could not be completed due to the resident's erratic behaviors. A Nurse Note dated [DATE], documented the dressing on Resident #97's left leg was saturated. The dressing was replaced but “got wet very quickly.” A Nurse Progress note dated [DATE], documented Resident #97's dressings applied on the afternoon of [DATE], appeared clean and dry with no visible drainage throughout the day. The resident complained of pain to both legs and the pain was relieved with scheduled and as needed (PRN) pain medications. A Wound Note dated [DATE], documented the dressings on Resident #97's LLE and the left dorsal foot had loose, green slough. The wound was soaked in wound cleanser and cleaned as much as possible. Medihoney was applied to all affected areas, covered with hydrofera blue. The venous stasis ulcers to the resident's LLE, posterior and lateral wounds, had decreased slough which was still green in appearance. A Nurse Note dated [DATE], documented Resident #97's dressings appeared soiled with clear fluid and the resident was leaving “wet marks” on the floor with the resident's heels. The note documented the resident refused a dressing change and yelled out “you are not going to touch me, you are going to hurt me, and you are going to kill me.” The note documented the resident was able to be redirected for short periods of time but did not document if wound care was or was not completed. A Nurse note dated [DATE], documented the dressings to Resident #97's bilateral lower extremities (BLE) were “soaking wet.” The bottom of the resident's left foot was macerated and the “top of the LLE was covered with thick slough.” The side of the resident's left foot had macerated tissue, and the tissue came off with the hydrofera blue. A thick layer of barrier cream was applied to the bottom of the resident's foot and covered as ordered. The note did not document the characteristics of the slough and drainage such as color, amount, and/or odor. A progress note dated [DATE], documented Resident #97 only slept for approximately one hour throughout night shift. The resident yelled and screamed “please help me, don't hurt me, somebody help me in the name of Jesus, and why can't you help me. Attempts to redirect the resident were not effective. A Wound note dated [DATE], documented Resident #97's wounds had increased green drainage and increased green slough. The wounds were minimally cleaned due to the resident would not allow debridement. A Physician's note, dated [DATE], documented Resident #97 verbalized being in severe pain and requested to be helped urgently. The resident pointed at the wounds on the resident's legs and verbalized the location of the pain was “down there.” The wounds were wrapped but leaking. The provider could not assess the wounds due to the resident moved backwards and verbalized “don't touch me.” The assessment notes follow up plan documented the resident was in significant pain and requested additional analgesia. The provider documented the resident's root of behavior arose from the resident needing to have psychiatric medications evaluated and treated by behavioral health. It was concerning due to the resident's refusal of wound care including debridement of the wound the resident may become septic, amputation was also likely. A Nurse Note dated [DATE], documented Resident #97 appeared to be doing mildly better following an increase in Ativan from 0.5 mg to 1.0 mg but did not effectively ease the resident's anxiety. A Nurse Note dated [DATE], documented Resident #97 had been crying out for several hours. The resident was in a lot of pain, and the prescribed pain medication appeared to be insufficient at allowing the resident to cope with the resident's pain. The resident's wound dressings were changed by the previous shift but were dripping wet by the middle of the following shift and new dressings had to be applied to the resident's LLE and foot. A Nurse Note dated [DATE], documented an increase in Ativan had not produced the desired effect. The resident had been begging for help and asking the nurse to not hurt or kill the resident. A Nurses Note, dated [DATE], written by ADON, documented Resident #97's dressing was soaking wet, and the resident was leaving wet marks on the floor. The wounds were cleansed with wound cleanser, barrier cream was applied to the peri-wound, and the wounds were covered. The wound bed to the top of the resident's left foot was covered with thick slough. The lateral side of her left foot was raw from maceration. The wounds had a large amount of drainage, and the resident appeared to have severe pain with dressing changes. A Nurses Note dated [DATE], at 4:35 PM, documented a Certified Nursing Assistant (CNA) reported to a nurse, Resident #97 was not “in the resident's normal state.” The resident was yelling out loud, pupils were not dilating, blood pressure was 64/44, heart rate was 66, and the resident's skin was hot to the touch. The resident had a temperature of 101.5. The resident was staring out into the distance and did not focus or track. Emergency Medical Services (EMS) was called and upon assessment could not get a reading of the resident's vital signs. The resident was transported by EMS to an acute care hospital. On [DATE] at 10:32 AM, the Director of Nursing (DON) explained the expectation was when a wound had copious drainage the wound care order would include a super absorbent dressing such as “Opti-lock” and additional padding such as an ABD pad. Alginates could be used to help facilitate drainage management. The DON verbalized the DON would expect to see an order for something to protect the peri-wound. The DON verbalized an attempt should be made to determine the cause of the excess drainage such as infection. The DON verbalized the DON's area of specialty was wound care. On [DATE] 10:36 AM the DON verbalized maceration indicated either the dressing was not changed often enough, or the correct dressing was not being used. The DON explained if honey was being used, the provider would be notified, and the honey would be discontinued. On [DATE] at 10:38 AM, the DON explained wound were only cultured if three symptoms were present such as heat from the wound, change in type of drainage, deterioration of the wound such as friable skin, and/or not responding to treatment. A topical dressing such as HFB or silver would be tried first due to antimicrobial properties and a culture and sensitivity would be ordered if the wound did not respond. The DON verbalized friable tissue was a sign of infection. On [DATE], at 1:35 PM, the DON confirmed wound care was not completed on 09/18 and [DATE] per TAR documentation and physician orders for Resident #97's wounds to the left dorsal foot, posterior LLE, and lateral LLE wounds. The DON confirmed if wound care could not be provided for any reason such as refused, it should be documented on the TAR. On [DATE] at 2:10 PM, the DON confirmed the last wound culture done for Resident #97 was documented as completed on [DATE], and there were not any additional lab values available during August and [DATE], including wound cultures. On [DATE] at 2:13, the DON confirmed wound care was not provided as ordered and confirmed drainage from the wound had not been well managed. The concern was the lack of management of the wound led to maceration and could have caused the deterioration of the wound and created an infection control concern. On [DATE] at 2:15 PM, the DON explained the presence of bacteria in a wound can cause wound healing to stall and result in the wound not being able to heal. [NAME] drainage indicated an infection, generally pseudomonas. Untreated infections could continue to spread, stall wound healing and place the resident at risk for sepsis. The DON confirmed when the wounds started to have green drainage a culture should have been completed and explained re-culturing the wound could have led to better wound management. On [DATE] at 2:40 PM, a Licensed Practical Nurse (LPN), who was the ADON during the time Resident #97 resided at the facility, recalled Resident #97's wounds were “pretty bad” and explained the resident often would not allow wound care. The LPN explained the resident refused wound care because it was so painful, and confirmed the resident had a lot of pain with her legs. The LPN recalled the resident would yell out regarding the resident's legs and explained the resident's legs looked “really bad” and were macerated. On [DATE] at 2:53 PM, the LPN verbalized a provider was in the facility throughout each day and had seen what was going on with the resident's legs and assessed the resident. On [DATE] at 2:54 PM, the LPN recalled seeing drainage on the floor but did not recall the color of the drainage. The LPN confirmed it did not take long for Resident #97's wound dressings to become soaked. The LPN explained the wounds would become saturated after approximately eight hours and the resident would leave a trail on the floor in the hallways and common areas. The resident never wanted to be in the resident's room. On [DATE] at 2:58 PM, the LPN recalled seeing drainage from Resident #97's wounds on the floor and described it as “dripping” onto the floor. The LPN explained staff tried to keep towels on the floor under the resident's feet/legs, but it was difficult because the resident would “freak out” when anyone got too close to the resident's legs, it was a constant struggle. The LPN confirmed placing towels on the floor under the resident's legs/feet was not an “effective form of infection control.” A hospital Discharge summary dated [DATE], documented Resident #97 was admitted to the acute care hospital on [DATE]. The resident was brought to the hospital by ambulance from the facility. Resident #97 was awake but had an altered mental status and was noted not to be at base line by hospital staff who were familiar with the resident. The resident was examined by an emergency room (ER) physician who documented the resident's lower extremity wound dressings appeared to have been there for quite some time. The resident was previously seen at the ER on [DATE], and the wounds were cleaned and dressed during the visit. The physician was concerned due to the appearance of the dressings; they had not been changed since they were applied in the ER. The resident was febrile with a temperature of 102.9 and was tachycardic with a heart rate of 126. The physician documented the resident was soiled and in pretty bad shape upon arrival. When the dressing was removed, flies came out from the wounds on the resident's legs. The resident was given Ativan, Toradol and other pain medications and was admitted to the hospital. The resident was suspected to have sepsis and was started on two antibiotics, vancomycin and Unasyn. The wounds to the resident's legs were described as denuded with the left leg worse than the right and wound cultures were collected. The report documented the resident had a high risk for morbidity. The Discharge Summary Report further documented on [DATE], Resident #97 passed away. The cause of death was sepsis secondary to lower extremity cellulitis, which was secondary to peripheral vascular disease. The facility policy titled “Infection Prevention and Control Program” reviewed on [DATE], documented the facility had established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Cross reference with F656 CPT 2289187 Resident #24 Resident #24 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including cerebral palsy, unspecified, other signs and symptoms involving cognitive functions and awareness, developmental disorder of speech and language, unspecified, and personal history of urinary tract infections. Resident #24's clinical record documented the resident was transferred and admitted to an acute care hospital on [DATE]. Resident #24's Care Plan documented the following focus areas, goals, and interventions/tasks: -Skin: Resident has the potential for altered skin integrity related to immobility, impaired cognition, malnutrition, and incontinence. Goal: Resident will not have new or worsening skin breakdown through next review. Interventions/Tasks: Nurses to perform weekly skin assessments, notify physician of any new skin impairments and obtain treatment orders as indicated. Monitor for and report to physician any signs/symptoms (s/s) of infection to skin impairments, for example: redness, warmth, swelling, drainage, odor, or elevated temperature. -Foley catheter: Resident has an indwelling catheter, 16 French, ten cubic centimeter (cc) balloon. Interventions/Tasks: Monitor/document for pain/discomfort due to catheter. A Nurses' Note dated [DATE], documented Resident #24 had leaking from the resident's indwelling catheter and sediment was noted in the catheter tubing. The nurse attempted to flush and aspirate the catheter, however, was unsuccessful as the catheter appeared to be clogged. A new catheter was inserted using aseptic technique. 100 cc of dark yellow urine returned. A Skilled Charting Note dated [DATE], documented 300 milliliters (ml) of dark/amber colored urine were drained from Resident #24's Foley catheter bag. A Nurses' Note dated [DATE] at 12:19 AM, documented Resident #24's scrotum was red and painful to the touch. Physician notified via book. A Nurses' Note dated [DATE] at 11:13 AM, documented during a bed bath staff noticed Resident #24's scrotum was enlarged and red, a nurse observed the area and noted the scrotum was red, warm, swollen, hard, and had purulent drainage in the penile area. Emergency Medical Services (EMS) was called at 10:42 AM and the resident left the facility via EMS at 11:04 AM. A Nurses' Note dated [DATE] at 11:27 AM, documented the nurse was notified of a change in Resident #24's condition. The resident's testicles were swollen to the size of a grapefruit, very hard, red, and hot to the touch. Purulent drainage was coming from around the resident's Foley catheter. Urine in the catheter drainage bag was amber with a moderate amount of sediment. The Director of Nursing (DON) was notified, report was given to the emergency room (ER) nurse and EMS was called for transport. A Hospital Medicine Daily Progress Note from an acute care hospital, dated [DATE], documented Resident #24 was admitted on [DATE] with testicular pain, epididymitis and orchitis consistent with pyocele. Urine cultures were positive for Pseudomonas and Enterococcus. The resident required treatment with intravenous Levaquin and enteral Amoxicillin. On [DATE] at 2:28 PM, the LPN/ADON verbalized if staff noted a change in a resident's skin or the resident was exhibiting s/s of possible infection, staff were to notify the resident's physician, enter a progress note, notify the resident's responsible party, and pass the information on in report to the next shift. The LPN/ADON verbalized nurses could contact the physician via phone or use the communication binder. If the notification was for a resident's change in condition such as a fall, change in mental status, or increased/decreased urinary output, the LPN/ADON verbalized the LPN/ADON would call the physician instead of using the communication binder. On [DATE] at 3:28 PM, the DON verbalized neglect was failure to provide things to a resident which could lead to inadequate quality of life and not providing the care and treatment the resident was supposed to have or was ordered by the physician. Training related to abuse and neglect was provided to staff every month and the Administrator was the facility's abuse coordinator. The DON explained a change in condition was anything different from the resident's baseline. The DON verbalized the DON would consider a newly identified area of redness and tenderness on a resident's skin a change in condition. The DON verbalized the DON's expectation of staff if there was a change in a resident's skin or the resident exhibited s/s of a possible infection was to notify the physician and facility management. Staff could contact the physician via phone or the facility's book which was reviewed by the physician on Fridays. The DON verbalized if a change in condition was urgent, placed the resident at risk or needed the physician's immediate attention staff were to call the physician and not use the communication book. The DON confirmed staff's failure to report a change in condition timely to the physician would be considered neglect. The DON reviewed Resident #24's clinical record and confirmed the Nurses' Note dated [DATE] at 12:19 AM documented the resident's scrotum was red and painful to touch and the physician was notified via book. On [DATE] at 9:52 AM, the DON verbalized the DON attempted to locate documentation of the physician notification regarding Resident #24's change in condition. The DON explained the facility did not retain the information communicated in the book after the physician reviewed it and the notes were not entered or scanned into the resident's clinical record. The DON confirmed the physician should have been notified via phone of Resident's #24's condition documented on [DATE] at 12:19 AM due to the resident exhibiting s/s of possible infection. On [DATE] at 11:51 AM, an LPN2 confirmed the LPN2 was familiar with Resident #24 and recalled the LPN2 had to send the resident to the hospital in the past. The LPN2 explained the nurse assigned to Resident #24 had gone on a break when a Certified Nursing Assistant (CNA) asked the LPN2 to assess the resident. Upon assessment, the LPN2 verbalized the LPN2 felt the resident needed to be transported to the ER immediately due to resident's testicles being swollen and red. The LPN2 called the physician, reported the condition of the resident, and received instruction to send the resident to the ER. The LPN2 verbalized the LPN2's concern at the time of the assessment was Resident #24 may have been experiencing a medical emergency such as testicular torsion or an infection. On [DATE] at 12:13 PM, during an interview with the Administrator and the Administrator in Training, the Administrator verbalized neglect was anything harming or affecting a resident in a negative way. The Administrator confirmed staff's failure to notify the physician timely of a change in a resident's condition or s/s of possible infection would be considered neglect. The Administrator explained if the facility had suspicion or an allegation of neglect or abuse was reported, the Administrator would initiate an investigation. Hospitalizations were reviewed by the interdisciplinary team for possible abuse and neglect. The Administrator verbalized the Administrator was familiar with Resident #24 and recalled the resident being hospitalized in [DATE] due to concern about the resident's scrotum. The Administrator believed the hospitalization was reviewed by the facility for possible abuse and neglect however, could not recall what was reviewed or the team's discussion and was unsure if the Administrator had documentation of the review. The Administrator verbalized notifying the physician of a change in a resident's condition through the communication book, as documented in the [DATE] at 12:19 AM Nurses' Note, was an “old” process and the Administrator believed the nurse who wrote the note may have written it in error. On [DATE] at 1:03 PM, the Administrator denied having documentation of the facility's review or investigation of Resident #24's hospitalization for potential abuse or neglect and denied having any additional documentation related to the physician being notified of the change in condition. The Administrator explained the interdisciplinary team's review process when a resident was transferred to the hospital typically included clinical record review. The intent was to identify anything the facility may have missed or the facility could have done better to prevent the hospitalization. The Administrator verbalized if during the review, the team were to see the physician was notified via book, the team would investigate as the book was not the correct way to notify the physician. The facility document titled Job Description: Licensed Practical Nurse or Registered Nurse, documented the primary purpose of the position was to identify and meet the medical, physical, and psychosocial needs of each resident. The nurse was to communicate changes in resident condition to the director of nursing, resident's provider, and resident's representative as indicated. Changes in resident condition included but were not limited to medical, cognitive or physical condition from the resident's baseline, new skin conditions, accidents/incidents, and changes in behavior which may require a change in the plan of care. The facility policy titled Notification of Changes, dated [DATE], documented the facility was to promptly inform the resident and consult with the resident's physician when there was a change requiring notification. Circumstances requiring notification included but were not limited to a significant change in the resident's physical, mental or psychosocial condition such as deterioration in health status, life-threatening conditions, clinical complications, and circumstances which required a need to alter treatment. Altering treatment included a new treatment or discontinuation of current treatment. The need to alter treatment significantly was defined as a need to stop a form of treatment due to adverse consequences or commence a new form of treatment/procedure/therapy to deal with a problem. The facility policy titled Abuse, Neglect, and Exploitation, dated [DATE], documented it was the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures which prohibited and prevented abuse, neglect, exploitation, and misappropriation of resident property. Neglect was defined as the failure of the facility, its employees, or service providers to provide goods and services to a resident which were necessary to avoid physical harm, pain, mental anguish, or emotional distress. Possible indicators of abuse included but were not limited to physical injury of a resident of unknown source and failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning, and positioning. The facility policy titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, dated [DATE], documented the facility would identify events, occurrences, patterns, and trends which may constitute neglect or abuse. An alleged violation was defined as a situation or occurrence observed or reported by staff, resident, relative, visitor, or others but had not yet been investigated and, if verified, could be noncompliance with the federal requirements related to mistreatment, exploitation, neglect, or abuse including injuries of unknown source. The facility would investigate all allegations and types of incidents as listed above in accordance with facility procedure for reporting/response. CPT 2587748

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to ensure a significant medication error did not occur when a resident was administered a penicillin antibiotic when the resident had a known penicillin allergy for 1 of 7 sampled residents (Resident #1). This deficient practice resulted in the resident being hospitalized after developing symptoms of an allergic reaction. Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including colostomy status, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and Alzheimer's disease, unspecified. A hospital Discharge summary, dated [DATE], documented the resident had anaphylactic reactions to penicillin. The allergies documented in the resident's electronic health record upon the resident's initial admission to the facility on [DATE], were morphine, sulfa antibiotics, and codeine. An Order Summary Report for Resident #1 documented amoxicillin-potassium clavulanate (Augmentin) 875-125 milligram tablets, give one tablet by mouth two times a day for colostomy wound infection for five days. The order start date was 06/26/2024. The June 2024 Medication Administration Record for Resident #1 documented the resident had received the Augmentin on the afternoon of 06/26/2024 and then twice daily from 06/27/2024 through 06/29/2024. The 06/30/2024 morning dose had been held because the resident was hospitalized . A Nurse's Note, dated 06/30/2024, documented the resident had rashes noted on the resident's entire back, upper extremities, and thigh. The resident's blood pressure was 90/50. A hospital Discharge summary, dated [DATE], documented the resident had presented to the Emergency Department on 06/30/2024, after the resident had been placed on Augmentin and developed a subsequent maculopapular (a mix of flat, discolored areas of skin and small raised bumps), pruritic (itching), diffuse rash with generalized weakness, nausea, and vomiting. The resident received intravenous methylprednisolone (a medication used to treat severe allergic reactions). A Nurse's Note, dated 07/06/2024, documented the resident was readmitted after being hospitalized for a rash related to antibiotic use. On 11/12/2024 at 1:49 PM, the Director of Nursing (DON) verbalized the hospital discharge summary would be reviewed for allergies when a resident had dementia and was a poor historian, such as Resident #1. The DON verbalized the resident had developed an infection around the resident's colostomy site and received Augmentin (an antibiotic belonging to the penicillin class of antibiotics) in the afternoon on 06/26/2024, and then a morning and afternoon dose on 06/27/2024 through 06/29/2024. The resident was sent to the hospital on the morning of 06/30/2024 after the resident developed a rash. The DON confirmed the hospital Discharge summary, dated [DATE], from the resident's hospital stay prior to the resident's initial admission to the facility on [DATE], documented the resident had an allergy to penicillin and the resident's allergies in the facility's electronic health record had not included the resident's allergy to penicillin. The DON confirmed the resident should not have received Augmentin if the resident had a penicillin allergy. The facility policy titled Administering Medications, revised 12/2012, documented allergies to medications would be checked and verified for each resident prior to administering medications. Complaint #NV00072366